expert systems in renal disease kent renal serviceuniversity of kentsalford hospital chris farmer...
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Expert Systems Expert Systems in Renal Diseasein Renal Disease
Kent Renal ServiceKent Renal Service University of KentUniversity of Kent Salford Salford HospitalHospitalChris FarmerChris FarmerBernhard Klebe Bernhard Klebe Jean IrvingJean Irving Donal O’DonoghueDonal O’DonoghuePaul StevensPaul Stevens Roger CooleyRoger Cooley Rachel MiddletonRachel MiddletonHelen HobbsHelen Hobbs
Referral Variance
SD
+2.0
0.0
-2.0
Referral variance Corrected for age, gender, ethnicity and populationExtremal Quotient 52.72Farmer C, Hobbs H, Klebe B, Stevens P
Referral Rates 2003-Referral Rates 2003-20062006
0
20
40
60
80
100
120
140
160
AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR
2003
2004
2005
2006
Proportion of Referrals Proportion of Referrals SeenSeen
0
10
20
30
40
50
60
70
80
90
100
JUN JULY AUG SEP OCT NOV DEC JAN FEB MAR APR MAY
2005
2006
Perc
en
tag
e
Outpatient ActivityOutpatient Activity
623 forms assessed623 forms assessed
53.2% Male53.2% Male
Median Age 59 (16-93)Median Age 59 (16-93)
Median SCr 124 Median SCr 124 mol/L (35-832)mol/L (35-832)
Median calculated GFR 50.4 Median calculated GFR 50.4
(4.7>90) ml/min(4.7>90) ml/min
John RI, Farmer CK, Abbs I, Stevens PE
Intervention in the Last Intervention in the Last YearYear
0
10
20
30
40
50
60
Biopsy BP Angioplasty Immunosupn Statin Aspirin Renal Comp
*
* Denotes number of biopsies performed ever
Possible to identify patients who could Possible to identify patients who could be discharged based on:be discharged based on:
Stable Chronic Kidney DiseaseStable Chronic Kidney DiseaseBlood Pressure under 140/85Blood Pressure under 140/85No alteration in treatment in the past yearNo alteration in treatment in the past year
29.8% of patients followed 29.8% of patients followed
upup
Possible to identify patients who could Possible to identify patients who could be discharged based on:be discharged based on:
Stable Chronic Kidney DiseaseStable Chronic Kidney DiseaseBlood Pressure under 140/85Blood Pressure under 140/85No alteration in treatment in the past yearNo alteration in treatment in the past year
29.8% of patients followed 29.8% of patients followed
upup
Provided there is a robust
follow up arrangement
UK Referral GuidelinesUK Referral GuidelinesNEOERICNEOERICAA
Per Per MillionMillion
ActionAction
Stage 3Stage 3 20472047 1262612626 Other Tests Other Tests Stable Stable
1818 111111 Refer Hb<11Refer Hb<11
2727 167167 Refer BP Refer BP >130/90 >130/90 On 3 agentsOn 3 agents
240240 14801480 Refer GFR Refer GFR fallingfalling
Stage 4Stage 4 4545 278278 Another test Another test then referthen refer
99 6060 ReferRefer
Stage 5Stage 5 55 3636 ReferRefer
UK Referral GuidelinesUK Referral GuidelinesNEOERICNEOERICAA
Per Per MillionMillion
ActionAction
Stage 3Stage 3 20472047 1262612626 Other Tests Other Tests Stable Stable
1818 111111 Refer Hb<11Refer Hb<11
2727 167167 Refer BP Refer BP >130/90 >130/90 On 3 agentsOn 3 agents
240240 14801480 Refer GFR Refer GFR fallingfalling
Stage 4Stage 4 4545 278278 Another test Another test then referthen refer
99 6060 ReferRefer
Stage 5Stage 5 55 3636 ReferRefer2
55
8
Referral Rates 2003-Referral Rates 2003-20062006
0
50
100
150
200
250
AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR
2003
2004
2005
2006
Referral Rates 2003-Referral Rates 2003-20062006
0
50
100
150
200
250
AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR JUN AUG OCT DEC FEB APR
2003
2004
2005
2006
ARF
Stage 5
Stage 4Unstable 3
Immunosuppressed
Stage 4 (stable)
Hypertension
Stable Stage 3
Stage 1 or 2
At Risk Populations
Intensive Management
Hospital Based Care
Community based care
Incr
easing
Lev
el
Of Car
e Nee
ded
Structured delivery of care
Expert System in Kidney Expert System in Kidney DiseaseDisease
Identify patients requiring intensive Identify patients requiring intensive managementmanagement
Facilitate robust follow up of patients Facilitate robust follow up of patients discharged from hospital based caredischarged from hospital based care
Provide patient specific guidance for further Provide patient specific guidance for further investigations of patients with CKDinvestigations of patients with CKD
Manage stable chronic kidney disease in the Manage stable chronic kidney disease in the communitycommunity
General Practice
Database Systems
Data Extraction
MIQUEST
Database
Reporting Tool
Complete Database
Study Data
Patient Reports
Decision Support
Expert System
General Practice
Database Systems
Data Extraction
MIQUEST
Database
Reporting Tool
Complete Database
Study Data
Patient Reports
Decision Support
Expert System
General Practice
Database Systems
Data Extraction
MIQUEST
Database
Reporting Tool
Complete Database
Study Data
Patient Reports
Decision Support
Expert System
General Practice
Database Systems
Data Extraction
MIQUEST
Database
Reporting Tool
Complete Database
Study Data
Patient Reports
Decision Support
Expert System
Patientid varchar (20)pracid intsex varchar(6)dob dategp varchar(8)regDate date
Creatinineid varchar (20)date datevalue intpracid int
ReportedGfrid varchar (20)date datevalue floatpracid int
Bpid varchar (20)date datesystolic intdiastolic intpracid int
Calciumid varchar (20)date datevalue floatpracid int
Hbid varchar (20)date datevalue floatpracid int
Phosphateid varchar (20)date datevalue floatpracid int
Potassiumid varchar (20)date datevalue floatpracid int
Pthid varchar (20)date datevalue intpracid int
Knownid varchar (20)code varchar(30)date datepracid int
Tables are linked by id and pracid to patient table.
Tables created by SetupDatabase and filled by MiqReader.
Resultid varchar (20)date datestage intexitno intpracid int FurtherAction
id varchar (20)date dateactionid int pracid intdone boolean
RecommendationsexitNo intrecommendation varchar(500)
Actionsactionid intaction varchar(30)
Practicepracid intname varchar(30)
KnownRubriccode varchar(30)rubric varchar(30)
Treatmentid varchar (20)code varchar(30)date datepracid inttype int
Drugcode varchar(30)rubric varchar(200)
Categorytype intcategory varchar(30)
Populationpracid intpopulation intdate date Gfr
id varchar (20)date datevalue floatpracid int
(may decide not to keep this – recalculable)
Diabeticid varchar (20)code varchar(30)date datepracid int
DiabeticRubriccode varchar(30)rubric varchar(30)
Glucoseid varchar (20)date datevalue intpracid int
HbA1cid varchar (20)date datevalue intpracid int
Cholesterolid varchar (20)Codedate datevalue intpracid int
Proteinuriaid varchar (20)Codedate datevalue intpracid int
Triglycerideid varchar (20)date datevalue intpracid int
PCR
id varchar (20)date datevalue intpracid int
Proteinuriaid varchar (20)Codedate datevalue intpracid int
GPDecisionid varchar (20)date datepracid intdecisionCode int
DecisionsdecisionCode intrubric varchar(30)
B12id varchar (20)Codedate datevalue intpracid int
Referralid varchar (20)code varchar(30)date datereferralType intpracid int
Initially to indicate clinic attendance
General Practice
Database Systems
Data Extraction
MIQUEST
Database
Reporting Tool
Complete Database
Study Data
Patient Reports
Decision Support
Expert System
DevelopmentDevelopment
Recruitment of GP SurgeriesRecruitment of GP Surgeries 8 Practices8 Practices 100,000 people registered with their GP100,000 people registered with their GP
Development of decision support tool and Development of decision support tool and secondary checking of outputssecondary checking of outputs
Development of “expert” areas such as rate Development of “expert” areas such as rate of decline of renal functionof decline of renal function
Implementation and checking in a second Implementation and checking in a second UK regionUK region
Cluster randomised controlled trial Cluster randomised controlled trial
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